ELECTRONIC AND STANDARDIZED BILLING REGULATIONS / RULEMAKING COMMENTS
45 DAY COMMENT PERIOD / NAME OF PERSON/ AFFILIATION / RESPONSE / ACTION
9792.5(a)(5)
Medical Billing & Payment Guide 2010 – 7.1(b); 7.2(a) and (b) / Commenter notes that insurers must remit payment within 15 days after receiving a clean claim electronically. However, it appears that penalty and interest still would not be applicable until 45 days after receipt of a clean claim.
Commenter inquires if the Division has considered adjusting the penalty/interest timeframe to 15 days in correlation with the new time limit for payment. If this was considered and not addressed in these regulations, the commenter questions why. / Matt Absher
Senior Associate
Triage Consulting Group
March 8, 2010
Written Comment / Disagree. Although Labor Code §4603.4 provides a 15-day time period for payment of bills, it does not provide a penalty or interest for failure to pay within the 15-day period. The statutory authority for penalty and interest is under Labor Code §4603.2 which requires payment within 45 working days of receipt of the bill (or 60 working days for a governmental entity.) / None.
Medical Billing & Payment Guide 2010 – 7.1(b); 7.2(a) and (b) / Commenter finds that these proposed regulations as well as the required forms will be beneficial to the California Workers’ Compensation program.
Commenter is concerned that the payment for medical treatment provided or authorized by the treating physician shall be paid within 15 working days. Commenter opines that this is a very short time frame considering how many claims a case manager reviews and the amount of medical bills related to those claims.
Commenter opines that California is very complex and would like to know if the Division would consider extending that time frame to at least 21 days. Commenter also questions if the payment of electronic bills will be subject to the same type of penalty as paper bills. / Vallerie Gallaway
Supervisor, Bill Processing Review
Claims Management, Inc.
April 19, 2010
Written Comment / Disagree. The requirement to pay electronically submitted bills within 15 working days is a statutory requirement. The Division does not have the discretion to extend the timeframe for payment to 21 days. The electronic billing statute, Labor Code §4603.4 does not have a penalty for failure to pay within 15 working days. However, undisputed bills remaining unpaid at 45 working days would be subject to Labor Codes §4603.2’s penalty provisions. The regulations have been drafted to conform to these time frames and penalty provisions. / None.
9792.5.1(c)(1)-(3) / Commenter opines that the California DWC should be adopting payment rules and guidelines based on the HIPAA version 5010, not version 4010. If version 4010 is adopted, California will be out of step with the industry. Most significantly, the compliance date (18 months after the effective date of this regulation) coincides and conflicts with the HIPAA 5010 adoption and implementation. Commenter strongly urges that California base all requirements on version 5010, not 4010. Moving forward with version 4010 will require an almost immediate migration to version 5010 to support the impending ICD-10 requirements. However, if version 4010 is going to be implemented, it should be consistent with the requirements implemented by Texas. Any additional requirements made to the existing version 4010 implemented by Texas would not be beneficial or productive for the workers’ compensation system when the rest of the industry is working to implement version 5010. / Susan Leonardi,
Senior Application Business Analyst
Mitchell International
April 23, 2010
Written Comments / Agree that the Division should revise the regulations to utilize the 5010 standards instead of the 4010 standards. / The regulations will be revised to propose adoption of the 5010 standards / implementation guides instead of the 4010 guides.
9792.5 - General / Commenter states that providers should be required to submit eBills. Commenter points out that Texas adopted the mandate for both providers and claim administrators/payers. The fact that claim administrators are required to support the electronic eBilling while providers are not can negatively affect the cost/benefit of implementing the eBill requirements. Implementation can be quite costly (especially for the new 277 transaction) and without a requirement that providers send eBills, the return on investment is likely to be low. / Susan Leonardi,
Senior Application Business Analyst
Mitchell International
April 23, 2010
Written Comments / Disagree. In Texas, the statute mandates electronic billing for both providers and payers. In California, Labor Code §4603.4 only mandates that employers (i.e. claims administrators) accept electronic bills. It would be beyond the statutory authority to require providers to utilize electronic billing. / None.
Medical Billing & Payment Guide 2010 – 7.1(b); 7.2(a) and (b) / Medical payments for eBills are due within 15 working days according to 7.2 Penalty (a) of the proposed Medical Billing and Payment Guide. Commenter questions if this will be enforced when a directive is issued from CMS for payers to hold claims for 10 days? Commenter references the following recent example received from CMS via email:
“Information Regarding the Holding of April Claims for Services Paid Under the 2010 Medicare physician Fee Schedule (3-26-2010)
The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare Physician Fee Schedule (MPFS). As you are aware, the Temporary Extension Act of 2010, enacted on March 2, 2010, extended the zero percent (0%) update to the 2010 MPFS through March 31, 2010.
CMS believes Congress is working to avert the negative update that will take effect April 1. Consequently, CMS has instructed its contractors to hold claims containing services paid under the MPFS (including anesthesia services) for the first 10 business days of April. This hold will only affect claims with dates of service April 1, 2010, and forward. In addition, the hold should have minimum impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt.
Be on the alert for more information about the 2010 Medicare Physician Fee Schedule Update.” / Susan Leonardi,
Senior Application Business Analyst
Mitchell International
April 23, 2010
Written Comments / Directives from the CMS to hold bills for payment under the Medicare Physician Fee Schedule are not applicable to payments under the California Official Medical Fee Schedule, including the physician schedule and all other workers’ compensation fee schedule. The statutory requirement to pay within 15 working days is not affected by Medicare payment holds. / None.
Medical Billing & Payment Guide 2010 – 6.0 (b)(1) / Commenter states that this section indicates that both the DWC Bill Adjustment Reason Codes and ANSI Claims Adjustment Codes should be used. For consistency, commenter recommends the use of only the ANSI CARCs rather than both the ASNI CARCs and the DWC Bill Adjustment Reason Codes. This would be consistent with other states’ adoptions of eBilling per their companion guides. / Susan Leonardi,
Senior Application Business Analyst
Mitchell International
April 23, 2010
Written Comments / Disagree. The commenter’s statement that the Section 6.0(b)(1) requires both the DWC Bill Adjustment Reason Codes and the ANSI Claims Adjustment Reason Codes (CARC) is incorrect. The section requires the ANSI Claims Adjustment Group Codes, not the Claims Adjustment Reason Codes. The Claims Adjustment Group Codes classify the general nature of the adjustment reason, and are not duplicative of the DWC Bill Adjustment Reason Code. In regard to the suggestion to use the CARCs instead of the DWC Bill Adjustment Reason Code, the DWC disagrees. The DWC Bill Adjustment Reason Codes provide more specific information than the CARCS and that information has been tailored to California and will improve communication of the reason for a bill adjustment. / None.
Medical Billing & Payment Guide 2010 –
Appendix B and Electronic Medical Billing and Payment Companion Guide, Chapter 7 / Commenter asks how “self-executing” penalties and interest will be paid. If the penalties and interest are supposed to be paid and reflected on the EOB (paper or 835), then the guide needs to include instructions for how this should be reflected (what adjustment codes would be used, etc.). / Susan Leonardi,
Senior Application Business Analyst
Mitchell International
April 23, 2010
Written Comments / Agree. A new DWC Bill Adjustment Reason Code is needed to explain that payment is being made for interest and increase due to late payment for paper EOBs and a corollary CARC is needed for electronic remittance advice. / Add a new DWC Bill Adjustment Reason Code G81 and add reference to CARC 225 to 1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk.
Electronic Medical Billing & Payment Companion Guide 2.2.1 California Prescribed Formats / It is proposed that 277 4040 be required for Health Care Claim Acknowledgement versus 277 4050 Optional for Health Care Claim Request for Additional Information. Can the 277 4050 be used for both the acknowledgement and the additional information? / Susan Leonardi,
Senior Application Business Analyst
Mitchell International
April 23, 2010
Written Comments / Disagree. This comment is technically moot as the modified proposal no longer requires use of the 277 4040 and 277 4050, but instead requires use of the ASC X12N/5010X214
Technical Report Type 3
Health Care Claim Acknowledgment (277)
January 2007 and the ASC X12/005010X213 Technical Report Type 3 Request for Additional Information (277). However, anticipating a similar comment regarding the new proposal, the DWC responds as follows. The ASC X12N/5010X214 Health Care Claim Acknowledgment (277) has a different purpose than the ASC X12/005010X213 Health Care Claim Request for Additional Information (277). The Acknowledgment’s purpose is stated in the Technical Report Type 3: “The ASC X12 Health Care Claim Acknowledgement (277) implementation guide
is a business application level acknowledgement for the ASC X12 Health Care Claim (837) transaction(s). This acknowledges the validity and acceptability of the claims at the pre-processing stage. Payers may pre-process claims to determine whether or not to introduce them to their adjudication system. This pre-adjudication process is performed so claims that are incorrectly formatted or missing information can be corrected and resubmitted by the provider. The level of editing in pre-adjudication programs will vary from system to system. Although the level of editing may vary, this transaction provides a standard method of reporting acknowledgement of claims. The business function identifies claims that are accepted for adjudication as well as those that are not accepted. This 277 transaction is the only notification of pre-adjudication claim status.” This 277 Acknowledgment is sent out early (within 2 days) and is an initial screen of the submission. On the other hand, the 277 Request for Additional Information purpose is for the payer or bill processor to request additional information. “The ASC X12 Health Care Claim Request for Additional Information (277) implementation guide addresses usage of the 277 as a request for additional information to support a health care claim or encounter. The 277 transaction provides the mechanism for asking questions or making requests for information about specific claims or service lines. The actual answer or additional information response is provided in the ASC X12 Additional Information to Support a Health Care Claim or Encounter (275).” [Emphasis in original, page 3.] / None.
Medical Billing & Payment Guide 2010 – Appendix B. Standard Explanation of Review / The first sentence of Appendix B in the DWC Medical Billing and Payment Guide (page 47) states: “Any EOR must include all of the data elements indicated as required in Appendix B - 2.0 Field Table for Standard Explanation of Review.” The table of required elements seems to be missing. / Susan Leonardi,
Senior Application Business Analyst
Mitchell International
April 23, 2010
Written Comments / Agree in part. The DWC disagrees with the statement that the table of required elements is missing, but agrees that the first sentence is not correct. Due to a typographical error, the first sentence of page 47 refers to Appendix B – 2.0 Field Table whereas it should refer to Appendix B – 3.0 Field. / Correct first sentence on page 47 to refer to Appendix B – 3.0.
General Comment: Electronic Medical Billing & Payment Companion Guide / Commenter supports the mandate that Claims Administrators must be able to accept and process electronic medical bill transactions where the provider or other billing entity has elected to submit them in that manner. The mandate further requires that when the Claims Administrator receives the bills electronically, functional responses should be provided to the submitter and that the remittance (the description of payments of or adjustments to the bill) should occur electronically.
However, commenter opines that there should be more language in the mandate that either directs provider adoption (that language is currently not present) or provides greater incentive for provider adoption. Workers’ Compensation Claims Administrators currently not or only partly capable of transacting electronically may incur significant expense in order to achieve that ability. Efforts should be exerted to ensure that the investment of time and money to achieve compliance is not done merely for the sake of compliance. / Andy Tolsma